Wiki Help with breast coding Revision of mastectomy

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MEZIESKY

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I need help with this one please. Dr. did a simple complete mastectomy on 9/14. Path showed positive margins. Now taking additional breast tissue.
Positive anterior margin, status post left mastectomy, Dr is calling it a Revision of a mastectomy ??
.

POSTOPERATIVE DIAGNOSIS: Positive anterior margin, status post left mastectomy,
ICD code C50.912.

PROCEDURE PERFORMED: Revision left breast mastectomy.

SURGEON:

ASSISTANT:

ANESTHESIA: General.

INDICATIONS: The patient is a pleasant 79-year-old woman who underwent
bilateral mastectomy recently and her left breast cancer was greater than 12 cm.
The pathology revealed a unifocal positive margin in the anterolateral aspect
of the breast and, based on these findings, I recommended reexcision. She was
agreeable. Details can be found in the medical record.

DESCRIPTION OF PROCEDURE: The patient was seen in holding and final questions
were answered. Her left mastectomy site was marked with a "yes" and she was
brought back to the OR and placed under general anesthesia. She was placed in
the right lateral position and the left lateral breast was prepped and draped in
the usual sterile fashion. A timeout was confirmed with the operating team and
we started by marking out an ellipse around the lateral aspect of the breast,
which took care of the dog ear. The ellipse measured 15 cm long by about 8 cm
vertically. We used the Peak PlasmaBlade to do the revision mastectomy without
much problem down to the lateral fascia and chest wall. The specimen was
oriented. The wound was irrigated and closed with Invanz, Vicryl staplers, and
4-0 Monocryl for the skin. No drains were placed. The patient tolerated the
procedure well. There was a 10 mL blood loss. All needle and sponge counts
were correct x2.
 
Sounds like the original "mastectomy" was not complete if he is re-excising breast tissue? CPT 19301 would be the appropriate code for re-excision of breast tissue. Maybe a review of the primary procedure he states was a "simple complete mastectomy" would be warranted? (7+ years Plastic & Reconstructive Surgery coding experience).
 
Thank you so much. I did add the original op-note for the "simple complete mastectomy." Would appreciate your thoughts on that.
Thank again.

delineated a fishmouth incision encompassing the nipple-areolar border, which
favored the inferior flap because of her pendulous breasts. In a similar
fashion, the right breast was mapped out, this time to include the previous
transverse incision in the upper aspect of the right breast.

Using the PEAK Plasma Blade, skin flaps were raised on the left side.
Dissection was carried up to the infraclavicular fascia. The breast tissue was
taken off the pectoralis down to the axilla and axillary fat pad was opened.
Careful dissection revealed 2 small sentinel nodes that were radioactive and
partially blue staining. Titanium clips were used to ligate lymphatics and
cautery was used to excise the lymph nodes without much difficulty and they were
sent to Pathology. Hemostasis was assured and we continued on our mastectomy.
Borders of dissection included the anterior axillary line laterally, the sternum
medially, and the inframammary groove inferiorly. Mastectomy was carried out
using the Peak PlasmaBlade and the specimen was removed including the fascia of
the pectoralis. Specimen was oriented and the wound irrigated. A JP was placed
through the inferior flap and secured with a nylon suture and the mastectomy was
closed with absorbable Vicryl staples using the Invanz stapler. Once the
primary closure was obtained, 25 mL of 0.5% Marcaine was placed through the JP
into the skin. The JP had been placed through a stab incision in the inferior
flap and secured with nylon. A clamp was placed at the skin level to keep the
anesthetic effect in and we turned to the contralateral side. Gloves and
instruments were changed and standard mastectomy was carried out on the right
side using similar borders for dissection. The Peak PlasmaBlade and clips were
used for hemostasis during the mastectomy and again, the pectoralis fascia was
removed with the specimen and oriented. The wound was irrigated. JP placed
through the stab incision inferior flap and secured with a nylon suture and the
Vicryl stapler was used to close the flaps primarily. Then, 25 mL of local
anesthetic was infused through the JP and secured at the skin with a hemostat
and skin sites were closed with staples bilaterally. The patient tolerated the
procedures well. JPs were hooked to bulb suction and dressings were applied in
standard fashion. The patient tolerated both procedures well. There was
minimal blood loss.
 
Hate to ask for more but both pathologies may be helpful as well. I think an original mastectomy was performed to a certain depth making this a simple mastectomy originally and the revision CPT of 19301 appropriate. I found this article helpful on describing the depths and degree of the different types of mastectomies and what is traditionally performed for each:
Let me know if there is more help I can provide!
 
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